Arteriovenous fistulae for access to hemodialysis in Chad : feasibility study of a medical civic action program by a French army surgical unit.

INTRODUCTION: Use of chronic intermittent hemodialysis is recent in Chad, where it remains underdeveloped. Vascular access is most commonly by catheter. The objective of our study was to demonstrate the feasibility of arteriovenous fistula (AVF) surgery for hemodialysis during deployments as part of the medical civic action program (MEDCAP). METHODS: We prospectively included all patients admitted for AVF creation at Camp Kossei forward surgical unit in N'Djamena (Chad) between December 2016 and February 2017. Surgery was performed by an experienced vascular surgeon. The data collected included age, sex, cause of kidney failure, type of anesthesia, AVF location, and the duration of the intervention and hospitalization. Patients were examined one month after the procedure to evaluate the functionality, morbidity, and mortality of the AVF. RESULTS: We performed 17 AVF in 3 months. Male to female ratio was 3. High blood pressure was the main cause of chronic kidney failure (55%). All interventions were conducted under locoregional anesthesia. Overall, 35% of fistulae were radiocephalic, 41% brachiocephalic, and 24% brachiobasilic. The mean duration of intervention was 58 minutes and that of hospitalization one day. No deaths occurred. Global morbidity, including non-functioning AVF, was 25%. CONCLUSION: Our study showed that AVF surgery is feasible during deployment, especially in Chad, and meets the needs of the local healthcare facilities. It should be developed and taught to local surgeons.

Effects of abomasal infusion of flaxseed (Linum usitatissimum) oil on microbial ß-glucuronidase activity and concentration of the mammalian lignan enterolactone in ruminal fluid, plasma, urine and milk of dairy cows.

Ruminal microbiota plays an important role in the conversion of plant lignans into mammalian lignans. The main mammalian lignan present in the milk of dairy cows fed flax products is enterolactone (EL). The objectives of the present study were to investigate the effects of abomasal infusion of flax oil on the metabolism of flax lignans and concentrations of EL in biological fluids of dairy cows. A total of six rumen-cannulated dairy cows were assigned within a 2 × 3 factorial arrangement of six treatments utilising flax hulls (0 and 15·9 % of DM) and abomasal infusion of flax oil (0, 250 and 500 g/d). There were six periods of 21 d each. Samples were collected during the last 7 d of each period and subjected to chemical analysis. Flax hull supplementation increased concentrations of EL in ruminal fluid, plasma, urine and milk, while flax oil infusion had no effect. Post-feeding, ß-glucuronidase activity in the ruminal fluid of cows infused with 250 g flax oil was significantly lower for cows fed hulls than for those fed the control diet. The present study demonstrated that the presence of a rich source of n-3 fatty acids such as flax oil in the small intestine does not interfere with the absorption of the mammalian lignan EL and that lower ruminal ß-glucuronidase activity had no effect on the conversion of flax lignans into EL in the rumen of dairy cows.

Abomasal or ruminal administration of flax oil and hulls on milk production, digestibility, and milk fatty acid profile of dairy cows.

Four ruminally fistulated primiparous lactating Holstein cows were assigned to a 4 × 4 Latin square design to determine the effects of the site of administration (rumen or abomasum) of flax oil and flax hulls on diet digestibility and milk fatty acid profile of dairy cows. The treatments were 1) oil and hulls administered in the rumen and abomasal infusion of water (RUM/RUM), 2) oil and hulls infused in the abomasum (ABO/ABO), 3) oil administered in the rumen and hulls infused in the abomasum (RUM/ABO), and 4) oil infused in the abomasum and hulls placed in the rumen (ABO/RUM). Cows on the ABO/ABO and RUM/RUM treatments had the highest and lowest amounts of basal dry matter eaten, respectively. Higher dry matter digestibility was obtained when flax oil bypassed the rumen (ABO/ABO and ABO/RUM) compared with when flax oil was administered directly in the rumen (RUM/ABO and RUM/RUM). Apparent digestibility of ether extract was higher when flax hulls were administered in the rumen (RUM/RUM and ABO/RUM) compared with when flax hulls were infused in the abomasum (ABO/ABO and RUM/ABO). The lowest digestibility of acid detergent fiber and neutral detergent fiber was obtained when both flax products were added in the rumen, which may be attributed to the high amount of oil present in the rumen (7.8% of total dry matter input). The lowest yield of 4% fat-corrected milk was obtained for cows on the RUM/RUM treatment, probably as a result of lower dry matter intake and digestibility of fiber. Milk concentrations of protein, fat, total solids, and lactose were similar among treatments. Administration of oil and hulls in the rumen resulted in the highest concentrations of intermediate products of biohydrogenation and total trans fatty acids in milk fat compared with the other treatments. All ratios of n-6 to n-3 fatty acids in milk fat were lower than the 4 to 1 ratio recommended to improve human health. These results suggest that the presence of both flax oil and flax hulls in the rumen decreases 4% fat-corrected milk yield and digestibility but provides a desirable fatty acid profile of milk to enhance consumers' health.

Milk composition, milk fatty acid profile, digestion, and ruminal fermentation in dairy cows fed whole flaxseed and calcium salts of flaxseed oil.

Four ruminally lactating Holstein cows averaging 602+/-25 kg of body weight and 64+/-6 d in milk at the beginning of the experiment were randomly assigned to a 4 x 4 Latin square design to determine the effects of feeding whole flaxseed and calcium salts of flaxseed oil on dry matter intake, digestibility, ruminal fermentation, milk production and composition, and milk fatty acid profile. The treatments were a control with no flaxseed products (CON) or a diet (on a dry matter basis) of 4.2% whole flaxseed (FLA), 1.9% calcium salts of flaxseed oil (SAL), or 2.3% whole flaxseed and 0.8% calcium salts of flaxseed oil (MIX). The 4 isonitrogenous and isoenergetic diets were fed for ad libitum intake. Experimental periods consisted of 21 d of diet adaptation and 7 d of data collection and sampling. Dry matter intake, digestibility, milk production, and milk concentrations of protein, lactose, urea N, and total solids did not differ among treatments. Ruminal pH was reduced for cows fed the CON diet compared with those fed the SAL diet. Propionate proportion was higher in ruminal fluid of cows fed CON than in that of those fed SAL, and cows fed the SAL and CON diets had ruminal propionate concentrations similar to those of cows fed the FLA and MIX diets. Butyrate concentration was numerically higher for cows fed the SAL diet compared with those fed the FLA diet. Milk fat concentration was lower for cows fed SAL than for those fed CON, and there was no difference between cows fed CON and those fed FLA and MIX. Milk yields of protein, fat, lactose, and total solids were similar among treatments. Concentrations of cis-9 18:1 and of intermediates of ruminal biohydrogenation of fatty acids such as trans-9 18:1 were higher in milk fat of cows fed SAL and MIX than for those fed the CON diet. Concentration of rumenic acid (cis-9, trans-11 18:2) in milk fat was increased by 63% when feeding SAL compared with FLA. Concentration of alpha-linolenic acid was higher in milk fat of cows fed SAL and MIX than in milk of cows fed CON (75 and 61%, respectively), whereas there was no difference between FLA and CON. Flaxseed products (FLA, SAL, and MIX diets) decreased the n-6 to n-3 fatty acid ratio in milk fat. Results confirm that flax products supplying 0.7 to 1.4% supplemental fat in the diet can slightly improve the nutritive value of milk fat for better human health.

Influence of parturition and diets enriched in n-3 or n-6 polyunsaturated fatty acids on immune response of dairy cows during the transition period.

The objectives of this study were to evaluate the functional properties of immunocompetent cells in dairy cows fed diets enriched in n-3 or n-6 polyunsaturated fatty acids during the transition period. Six weeks before calving, 21 primiparous and 27 multiparous pregnant Holstein dairy cows were randomly allotted to 1 of 3 dietary fat treatments: calcium salts of palm oil (Megalac), micronized soybeans, or whole flaxseed, which are, respectively, rich in saturated, n-6, or n-3 fatty acids. On wk 6 and 3 before parturition, cows received a subcutaneous injection of ovalbumin to measure the antibody response in colostrum and serum. Colostrum samples were collected at the first milking after calving, and blood samples were taken 6, 3, and 1 wk before the expected calving date and 1, 3, and 6 wk after calving. Blood mononuclear cells were cultured to evaluate the proliferative response to concanavalin A and the in vitro productions of interferon-gamma, tumor necrosis factor-alpha, nitric oxide, and prostaglandin E2. The serum antibody response to ovalbumin was unaffected by dietary fatty acids, but the response was lower in primiparous cows than in multiparous cows. A significant diet x parity interaction indicated that colostral antibody level against ovalbumin was significantly higher in multiparous cows fed soybeans than in those fed flaxseed or Megalac; there was no difference among treatments for primiparous cows. The lymphocyte response to concanavalin A was lower in cows fed soybeans than in those receiving flaxseed or Megalac when the cells were incubated with autologous serum. The proliferative response of mononuclear cells incubated with autologous serum was suppressed in the 1st wk after calving in both primiparous and multiparous cows, and multiparous cows showed a higher response than primiparous cows throughout the experiment. There was a significant interaction between parity and diet as a result of a greater production of interferon-gamma by mononuclear cells incubated with autologous serum in multiparous cows than in primiparous cows fed flaxseed; there was no difference among cows fed the other diets. Interferon-gamma production was reduced around calving while the inverse was observed for productions of nitric oxide and tumor necrosis factor-alpha. Productions of nitric oxide, prostaglandin E2, and tumor necrosis factor-gamma were greater in primiparous cows than in multiparous cows. In conclusion, functional properties of lymphocytes and monocyte/macrophage lineage of dairy cows during the transition period are modulated by parturition and the composition of polyunsaturated fatty acids in the diet.

Immune response of postpartum dairy cows fed flaxseed.

Thirty Holstein cows were allotted at calving to 10 groups of three cows blocked for similar calving dates to determine the effects of dietary fatty acids on functional properties of immunocompetent cells in early lactation and at breeding. Cows were assigned at calving to one of three isonitrogenous, isoenergetic, and isolipidic supplements based on either calcium salts of palm oil, Megalac, micronized soybeans, or whole flaxseed. On the day of AI and 20 d later, cows were injected with ovalbumin to measure the antibody response. Blood samples were taken at different times after calving (d 5, 21, 42, and 105) and after AI (d 0, 10, 20, and 40) for quantification of serum progesterone, fatty acids, and prostaglandin E2 concentrations. Isolated peripheral blood mononuclear cells were cultured to evaluate the proliferative response to concanavalin A and in vitro productions of interferon-gamma and prostaglandin E2. In general, feeding flaxseed increased serum omega-3 fatty acids concentration compared with feeding Megalac or soybeans, which decreased the omega-6 to omega-3 fatty acids ratio. There was a significant diet x day interaction for the proliferative response of mononuclear cells after calving and AI, indicating that cell responses from cows fed flaxseed were transiently reduced compared with those fed Megalac and soybeans. Moreover, during the breeding period, serum progesterone concentration was significantly greater in cows fed flaxseed compared with those fed Megalac, whereas serum concentration of prostaglandin E2 was significantly lower in cows fed flaxseed than in those fed Megalac or soybeans. Dietary treatments had no effect on the antibody response to ovalbumin and on in vitro productions of interferon-gamma and prostaglandin E2. However, interferon-gamma and prostaglandin E2 were impaired in the first 3 wk after parturition regardless of dietary treatment. These results suggest that changes in fatty acids, progesterone, and prostaglandins E2 concentrations in serum due to dietary treatment and physiological status influenced systemic immunity as shown by reduced proliferative response. However, other mechanisms must be considered and are discussed to explain dietary effect on lymphocyte proliferative response to mitogenic stimulation and other immune functions.

Juvenile fibromyalgia syndrome: proposed management using a cognitive-behavioral approach.

In recent years, fibromyalgia has become an increasingly recognized chronic syndrome. Although it occurs more frequently in adults, it is also seen among school-age children and adolescents. In such cases, it is known as juvenile fibromyalgia syndrome (JFS). The widespread pain and other possible symptoms associated with JFS can have a negative impact on the occupational performance and developmental tasks of children and adolescents. As experts in the areas of occupational performance, daily functional skills, and child development, occupational therapists have a potential role to play in the assessment and management of children and adolescents with JFS. To date, however, no occupational therapy management approach for clients with JFS has been documented in the professional literature. In this paper, we outline the clinical features of JFS, pertinent assessment areas, and potential management strategies using a cognitive-behavioral approach.

Calmodulin inhibitors trigger the proteolytic processing of membrane type-1 matrix metalloproteinase, but not its shedding in glioblastoma cells.

Most transmembrane proteins are subjected to limited proteolysis by cellular proteases, and stimulation of cleavage of membrane proteins by calmodulin (CaM) inhibitors was recently shown. The present study investigated the ability of several CaM inhibitors to induce the proteolytic cleavage of the membrane type-1 matrix metalloproteinase (MT1-MMP) from the cell surface of highly invasive U-87 glioblastoma cells. Although no shedding of a soluble MT1-MMP form was induced by CaM inhibitors in the conditioned media, we showed that these inhibitors induced MT1-MMP proteolytic processing to the 43 kDa membrane-bound inactive form that was not correlated with an increase in proMMP-2 activation but rather with an increase in tissue inhibitor of MMPs (TIMP)-2 expression levels. Moreover, this proteolytic processing was sensitive to marimastat suggesting the involvement of MMPs. Interestingly, CaM inhibitors antagonized concanavalin A- and cytochalasin D-induced proMMP-2 activation, and affected the cytoskeletal actin organization resulting in the loss of migratory potential of U-87 glioblastoma cells. Cytoplasmic tail-truncated MT1-MMP constructs expressed in COS-7 cells were also affected by CaM inhibitors suggesting that these inhibitors stimulated MT1-MMP proteolytic processing by mechanisms independent of the CaM-substrate interaction. We also propose that TIMP-2 acts as a negative regulator of MT1-MMP-dependent activities promoted by the action of CaM inhibitors in U-87 glioblastoma cells.

Activation of the extracellular signal-regulated protein kinase (ERK) cascade by membrane-type-1 matrix metalloproteinase (MT1-MMP).

The mechanisms underlying membrane-type-1 matrix metalloproteinase (MT1-MMP)-dependent induction of cell migration were investigated. Overexpression of MT1-MMP induced a marked increase in cell migration, this increase being dependent on the presence of the cytoplasmic domain of the protein. MT1-MMP-dependent migration was inhibited by a mitogen-activated protein kinase kinase 1 inhibitor, suggesting the involvement of the extracellular signal-regulated protein kinase (ERK) cascade in the induction of migration. Accordingly, MT1-MMP overexpression induced the activation of ERK, this process being also dependent on the presence of its cytoplasmic domain. MT1-MMP-induced activation of both migration and ERK required the catalytic activity of the enzyme as well as attachment of the cells to matrix proteins. The MT1-MMP-dependent activation of ERK was correlated with the activation of transcription through the serum response element, whereas other promoters were unaffected. Taken together, these results indicate that MT1-MMP trigger important changes in cellular signal transduction events, leading to cell migration and to gene transcription, and that these signals possibly originate from the cytoplasmic domain of the protein.

Localization of membrane-type 1 matrix metalloproteinase in caveolae membrane domains.

Membrane-type 1 matrix metalloproteinase (MT1-MMP) is a membrane-associated MMP that has been recently reported to have a central role in tumour cell invasion. Here we report that both the native and overexpressed recombinant forms of MT1-MMP are highly enriched in low-density Triton X-100-insoluble membrane domains that contain the caveolar marker protein caveolin 1. Moreover, the MT1-MMP-dependent activation of proMMP-2 induced by concanavalin A and cytochalasin D was correlated with the processing of MT1-MMP to its proteolytically inactive 43 kDa fragment in U-87 glioblastoma and HT-1080 fibrosarcoma tumour cell lines; this processing was also preferentially observed within the caveolar fraction. Interestingly, whereas the expression of caveolin 1 had no effect on the MT1-MMP-dependent activation of proMMP-2, its co-expression with MT1-MMP antagonized the MT1-MMP-increased migratory potential of COS-7 cells. Taken together, our results provide evidence that MT1-MMP is preferentially compartmentalized and proteolytically processed in caveolae of cancer cells. The inhibition of MT1-MMP-dependent cell migration by caveolin 1 also suggests that the localization of MT1-MMP to caveolin-enriched domains might have an important function in the control of its enzymic activity.

Snoring, apnea, and nasal resistance.

OBJECTIVE: To understand the impact of the nose in relation to snoring, to increased and decreased nasal resistance and sleep, to nasal anatomy and physiology in snorers and apneic patients, and to nocturnal episodes of respiratory obstruction in relation to nasal obstruction. DESIGN: A select group of patients, in whom nasal reconstruction and uvulopalatopharyngoplasty (UPPP) were combined, were studied. A review of the literature is included. METHODS: A questionnaire was given to all patients. MAIN OUTCOME MEASURES: Patients' snoring improvement was evaluated postoperatively. RESULTS: Overall, 174 of the 180 patients (97%) believed their snoring to be improved postoperatively after combined nasal reconstruction and UPPP were done. CONCLUSION: A review of the literature, a review of snorers' pathophysiology, and the results of this study show that nasal surgery and UPPP combined are effective in improving snoring.

Priming of human monocytes with leukotriene B4 enhances their sensitivity in IL-2-driven tumor necrosis factor-alpha production. Transcriptional and post-transcriptional up-regulation of IL-2 receptors.

Cytotoxic activity of monocytes may be mediated by their production of TNF-alpha, and IL-2 has been shown to induce TNF-alpha production in monocytes and alveolar macrophages. Unstimulated human monocytes constitutively express the beta-chain of the IL-2R (IL-2R beta), but little or no IL-2R alpha. When monocytes were pretreated with leukotriene (LT) B4, they responded to IL-2 with both enhanced production of TNF-alpha (two- to threefold) and, more strikingly, with augmented sensitivity (1000-fold) to IL-2. Treatment of monocytes with LTB4 induced IL-2R alpha gene transcription at 30 min and augmented expression of IL-2R alpha gene transcripts by 3 h, maximal at 10(-8) M LTB4. LTB4 induced increased shedding of the IL-2R alpha in the culture supernatants and a modest induction of IL-2R alpha protein expression on monocytes. On the other hand, although LTB4 could stimulate the cell membrane expression of IL-2R beta and the accumulation of IL-2R beta mRNA, LTB4 did not significantly affect IL-2R beta gene transcription. The augmented expression of IL-2R on monocytes was associated with augmented binding of 125I-labeled IL-2 to LTB4-pretreated monocytes. Our data present direct evidence that the inflammatory lipid mediator LTB4 can induce the expression of IL-2R alpha in human monocytes by activating IL-2R alpha gene transcription; it can also stimulate the expression of IL-2R beta, through post-transcriptional regulation; this augmented expression of both alpha- and beta-chains of the IL-2R is associated with enhanced sensitivity of monocytes to IL-2 in terms of TNF-alpha production and may be relevant to the proinflammatory actions of LTB4.

Stability of famotidine in polyvinyl chloride minibags and polypropylene syringes and compatibility of famotidine with selected drugs.

OBJECTIVE: (1) to determine the stability of famotidine 200 micrograms/mL in admixtures with dextrose 5% injection (D5W) and NaCl 0.9% injection (NS) in polyvinyl chloride (PVC) minibags and polypropylene syringes, at room temperature (22 degrees C), protected and unprotected from light for 15 days; and (2) to evaluate the visual compatibility of famotidine with 34 selected drugs for four hours at room temperature. DESIGN: Concentration of famotidine samples was determined on day 0 and again on days 3, 6, 9, 12, and 15 by a stability-indicating HPLC. Inspection for visual and pH changes was also performed at these time intervals. RESULTS: More than 95 percent of the day 0 famotidine concentration remained in all samples over the 15-day study period. During this period, all samples remained clear and colorless and no change in absorbance at 450 and 540 nm was observed. The pH of the samples also remained unchanged. Famotidine 2000 micrograms/mL was found to be compatible with 33 selected drugs; only furosemide was found to be incompatible. A white precipitate was observed when an equal volume of famotidine 2000 micrograms/mL in NS was mixed with furosemide 3000 micrograms/mL in D5W. The concentration of famotidine in the supernatant gradually decreased during the 4-hour study period. At 0.5, 1.0, 2.0, and 4.0 hours after mixture of famotidine with furosemide, famotidine concentrations were 97.5, 23.6, 21.7, and 17.2 percent of the initial famotidine concentration, respectively. CONCLUSIONS: Our results show that famotidine 200 micrograms/mL was stable in admixture with D5W and NS in PVC minibags and polypropylene syringes when these solutions were stored at room temperature, protected and unprotected from light for 15 days. Famotidine 2000 micrograms/mL in NS was compatible with 33 of the drugs, and was incompatible with furosemide.

Differential regulation of cytokine and cytokine receptor genes by PAF, LTB4 and PGE2.

Immune and inflammatory responses involve a whole array of cells and cell products which interact and mutually regulate each other. Many of these interactions are mediated by cytokines acting through specific receptors. Furthermore, lipid mediators such as PAF and the arachidonic acid metabolites LTB4 and PGE2 are known to affect several of the mechanisms involved in the regulation of the immune and inflammatory responses. In this paper, we review recent data from our laboratory illustrating the differential regulation of IL-6 and TNF alpha production and IL-2 receptor alpha and beta expression by these lipid mediators. We show that the regulation of these genes is both transcriptional and post-transcriptional, and that LT and PG can also be involved as second messengers in these regulatory processes.

Leukotriene B4 augments interleukin-2 receptor-beta (IL-2R beta) expression and IL-2R beta-mediated cytotoxic response in human peripheral blood lymphocytes.

Interleukin-2 can induce cytolytic activity in human peripheral blood lymphocytes and this activation is mediated by the beta chain of the interleukin-2 receptor-beta (IL-2R beta). Leukotriene B4 (LTB4) is a potent lipid inflammatory mediator which induces IL-2 and interferon-gamma (IFN-gamma) production from T cells. We examined the ability of LTB4 to modulate IL-2-induced cytolytic activity. Peripheral blood lymphocytes which had been preincubated for 24 hr in the presence of LTB4 responded to 100-fold lower concentrations of IL-2 with an augmentation of natural killer (NK) cell cytotoxic activity. Furthermore, incubation of lymphocytes with graded concentrations of LTB4 augmented the proportion of IL-2R beta+ cells. Peak activity was seen at 10 nM LTB4 and was comparable to that of PHA. By two-colour cytofluorometry, the increased expression of IL-2R beta was found predominantly on CD56+ cells and to a lesser extent on CD8+ cells, while CD4+ cells were unaffected. These observations were correlated at the messenger RNA (mRNA) level with increased IL-2R beta mRNA accumulation following stimulation of purified CD56+ and CD8+ cells with LTB4. CD56-, CD8- cells did not respond to LTB4 by increased IL-2R beta mRNA accumulation. Our data indicate, for the first time, that LTB4 can markedly increase the sensitivity of non-major histocompatibility complex (MHC)-restricted cytotoxic lymphocytes to IL-2, in terms of IL-2-dependent cytotoxic responses, and that this sensitivity is associated with augmented IL-2R beta gene message and cell surface expression.

[Snoring: physiopathology, surgical treatment and a modified uvulo-palato-pharyngoplasty]. / Le ronflement: physiopathologie traitement chirurgical et technique modifee d'uvulo-palato-pharyngoplastie.

Sleep apnea, now recognized as a specific clinicopathological entity, had received little attention until late 1960 when described by Gastaud. Since that time, following the works of Ikematsu, Guillemineault and Fujita, there has been rapid extension in the knowledge and understanding of sleep problems and associated surgery. Snoring, whether part of the sleep apnea syndrome or alone, may be explained with the help of an aerodynamic model comparing the pharynx to a Starling resistance. The factors nasal obstruction, abnormal mass in the upper respiratory airways and transmural resistance are discussed in the light of this model. To modify some of the above factors, surgical techniques have been described. We feel these conventional techniques do not take into account the normal healing process of inverted double C scars. We have modified the classic technique by sectioning the palatopharyngeus muscle and used Z-plasty to close the surgical defect. This is followed by a limited resection of the soft palate. As a consequence, the soft palate is being brought forward in the healing process and the oropharynx AP diameter is enlarged. This minimal type of resection of the soft palate precludes complications of velopharyngeal incompetency or relative pharyngeal stenosis. We have studied 200 snorers and operated on 90 of them, 25 according to the standard technique and 65 with the modified technique. The modified technique, while limiting the amount of palate to be removed and also the morbidity, is easy to standardize and offers as good results with fewer risks.

Facial reinnervation after facial paralysis: is it ever too late?

Following Conley's work on facial nerve cross-over surgery in long-standing facial paralysis, we have reviewed five cases of paralysis of 2.5-7 years' duration. All had complete absence of electrical activity on preoperative EMG and ENG studies. In four of the five cases the facial nerve was not severely atrophic and a "cross-over" technique was feasible. Post-operatively, the results were electrically and clinically good to excellent. To foresee the results of facial nerve cross-over surgery, we have found that the degree of atrophy of the affected nerve at the time of reconstructive surgery is a more important factor than the time lapse since the beginning of the paralysis. Those results also seem better in younger patients. Our findings suggest that hypoglossal-facial cross-overs be considered even 3 years after a paralysis, mostly in younger patients, when the nerve is not severely atrophic. In some cases this technique can be complemented by muscular transfers or selected cosmetic surgery.

Extracranial and intracranial meningiomas.

Meningiomas constitute about 18% of primary intracranial tumors, and they are rarely observed in patients under 30 years of age. In this study, we present the case of a 17-year-old patient who was first seen for a right cervical mass. Further investigation revealed that a meningioma of the posterior cranial fossa had invaded the temporal bone, the infratemporal fossa and the right parapharyngeal region and was at the origin of that cervical mass. This intra- and extracranial meningioma was completely resected in two stages with very satisfactory results. We have reviewed the literature pertaining to the extracranial extensions of meningiomas originating in the posterior fossa.